TOPOFF showdown: Mask confusion reigns in terrorism drill in CT and NJ
The CDC and OSHA sought a compromise on masks vs. respirators
If another major terrorist event occurs in the United States, the protection of health care workers may be affected by confusion over who’s in charge and what respiratory protection is needed, safety experts say.
Those issues arose from the recent TOPOFF3 exercise in New Jersey and Connecticut — an extensive anti-terrorism drill that simulated biological and chemical terrorist attacks. The drill involved about 84 New Jersey hospitals and 32 Connecticut hospitals, with volunteer actors who flooded hospitals as panicked “patients.” The drill involved more than 10,000 “deaths” and more than 30,000 casualties.
Even before TOPOFF3 began, the Centers for Disease Control and Prevention (CDC) in Atlanta and the U.S. Occupational Safety and Health Administration (OSHA) clashed over what respiratory protection should be used against pneumonic plague in the exercise — and in the case of a real-life event. That issue also arose in TOPOFF2, the previous exercise held in Chicago in 2003, and was never resolved.
OSHA insisted that fit-tested filtering facepiece respirators should be used in such a bioterrorism event because public health authorities wouldn’t immediately know enough about the organism, which could be genetically engineered to be more transmissible. The CDC asserted that, because pneumonic plague is spread through droplets, surgical masks would be sufficient as barrier protection.
The New Jersey Department of Health and Senior Services in Trenton stepped in with guidance on personal protective equipment (PPE). “We were, certainly prior to TOPOFF and during TOPOFF, doing our very best to harmonize the messages between CDC and OSHA on how health care workers could best protect themselves,” says James Blumenstock, the agency’s deputy commissioner for health protection and preparedness.
Leadership conflicts occur, as well, regarding the role of local vs. federal authorities, says Joseph T. Hughes Jr., director of the National Institute for Environmental Health and Safety Worker Education & Training Program in Research Triangle Park, NC.
“When we get into these mass casualty disasters of national significance, it becomes fuzzy whether local people make the decisions or whether federal people tell you want to do,” he says.
In the TOPOFF3 exercise, the New Jersey Hospital Association (NJHA) in Princeton took a leading position providing some cohesiveness among the hospitals. They held conference calls every morning of the exercise to update hospitals and answer questions. They took their guidance from the New Jersey Department of Health and Senior Services, says Valerie Sellers, MHA, CHE, NJHA’s senior vice president for health planning and research.
The backdrop of bioterrorism revealed how agency disagreements could affect emergency response. OSHA and CDC tried to resolve the respiratory protection conflict and actually forged a compromise. That guidance on pneumonic plague, which appeared briefly on the CDC web site, stated that hospitals should use N95 filtering facepiece respirators in a bioterrorism event involving pneumonic plague. But if the respirators weren’t available or hadn’t been fit-tested, health care workers could wear surgical masks or nonfit-tested respirators because pneumonic plague is transmitted by droplets, the guidance said.
“We felt it would be prudent to step up the level of PPE in an event like that to protect workers,” says Don Wright, MD, director of OSHA’s Office of Occupational Medicine, who helped forge the compromise. “We felt it was potentially a mistake to assume that pneumonic plague used in a weaponized event would be the same as one that occurred in a naturally occurring event.
“They went from a document that surgical masks were adequate to protect health care workers to the statement that it might be prudent in the event of a bioterrorism event to up the level of protection. We were pleased with that result,” he says.
However, unions that represent health care workers were not pleased with the guidance. They later complained about the CDC plague guidance, arguing that surgical masks should not be recommended at all as protection during a bioterrorism attack. CDC withdrew the guidance from its web site, calling it a draft document.
Even during the TOPOFF exercise, conflicting messages caused confusion, says Blumenstock. “I think the TOPOFF3 exercise brought to a head the possible conflicts in policy between CDC and OSHA with regard to the appropriate level of respiratory protection,” he says. “In our after-action analysis, that is one of the issues to reflect on.”
The decisive factor in choosing respiratory protection is the identification of the organism, says Eddy A. Bresnitz, MD, MS, deputy commissioner of New Jersey Public Health Services and State Epidemiologist. “We all said, ‘If you’re not sure what it is, an N95 is appropriate.’ Once you know, a surgical mask is fine. If workers want to have an N95 respirator, they should be provided that, with appropriate fit-testing.”
That may prove a sticking point for hospitals where the administration and workers may have different opinions about what level of respiratory protection is adequate.
Can you use gauze?
TOPOFF3 intentionally strained the resources of the participants. In the process, it provided lessons about everything from supplies to staffing.
The incident began when patients arrived at hospitals in Union and Middlesex counties with a mysterious, flulike illness. By the next day, 92 people had died in 12 New Jersey counties and more than 2,000 victims needed care. The disease was identified as pneumonic plague, spread with a sprayer device mounted on an abandoned SUV. The state announced a plan to provide prophylactic antibiotics to health care workers from the national stockpile.
By Day 3, hospitals were overwhelmed, and staff absenteeism was rising. Federal authorities arranged an airlift called “Operation Exodus” to transfer patients to hospitals in Dallas.
By Day 5, the outbreak subsided. About 10,000 people had died, and more than 29,000 had fallen ill. Pneumonic plague affected 28 states.
When hospitals began to run low on respirators and surgical masks, which they placed on patients as well as health care workers, the distributors were instructed to tell them that the supplies had been depleted.
“One hospital actually started using gauze and rubber bands to protect [health care workers],” Sellers notes. “Another cut up bed sheets. The problem with that is that you can run out of bed sheets, too. They tried to find some creative ways to allow for some protection while they awaited replenishment of their supplies.”
The exercise forced hospitals to think about supply issues and health care worker protection. “If we can get them to think about it, we would hope an effective response [will be] included in their plan,” she says.
TOPOFF3 also assumed absenteeism of hospital staff who feared contracting plague. For example, hospitals were told that 50% of their staff were out. Hospitals had plans to distribute prophylactic antibiotics to the health care workers and their families. “You want to make sure your employees and their family members have access to the prophylactic antibiotics and [will] be protected,” Sellers adds.
If another major terrorist event occurs in the United States, the protection of health care workers may be affected by confusion over whos in charge and what respiratory protection is needed, safety experts say.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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